Madison County School System

							                     Madison County School System
                    “Little Buddy” Preschool Program
                 Registration for 2010-2011 School Year



Student’s Name________________                    DOB_______________

Parent’s Name(s):____________________________________

Address:__________________________________________

Phone Numbers: Home___________ Work/Cell____________

Emergency Contact Number____________________________
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Has your child attended previous preschool program(s)?   Yes______ No______

Does your child have any medical needs?            Yes______ No______
(If Yes, please indicate_____________________________________________

List Medications Your Child Presently Takes_____________________________

Does your child have any allergies?                      Yes______ No______

Does your child have any allergies to foods?       Yes______ No______
(If Yes, please indicate_____________________________________________

Is your child successfully toilet trained                Yes______ No______

Does your child sleep during nap times?                  Yes______ No______

Tell us about your child’s areas of strength:______________________________
______________________________________________________________
______________________________________________________________

Tell us about areas of learning your child is still developing___________________
______________________________________________________________
______________________________________________________________